UK: Improving Access to Psychological Therapies (IAPT) articles, blogs and discussion

The IAPT Double Myth of Economic and Clinical Utility
There is not just a gap between the psychological treatments delivered in randomised controlled trials and what comes to pass in routine psychological services, such as the Improving Access to Psychological Therapies Programme (IAPT) service, but a chasm. Efforts to have a meaningful debate on the issue have been met with a deafening silence. In the silence, the scope of psychological treatments has gradually been expanded, beyond the initial focus of depression and the anxiety disorders to include patients with long term physical conditions – a psychological imperialism. The power-holders definition of the outcome of routine psychological treatment reigns.
Click to expand...

http://www.cbtwatch.com/the-iapt-double-myth-of-economic-and-clinical-utility/
 
just spotted this on an NHS site

Conditions we work with
Medically unexplained symptoms
Medically unexplained symptoms (MUS) conditions which include:
  • fibromyalgia
  • chronic pain
  • chronic fatigue syndrome (CFS) / myalgic encephalomyelitis (ME)
  • irritable bowel syndrome (IBS)
  • Multiple sclerosis (MS)
Click to expand...

since when do they include MS as MUS?

https://www.talkingtherapies.nelft.nhs.uk/long-term-conditions/
 
Sly Saint said:
since when do they include MS as MUS?
Click to expand...

I don't know. But I think common gynaecology issues (endometriosis, fibroids, PCOS, ovarian cysts etc) are gradually being moved into IAPT and MUS as well. Doctors never want to test and/or diagnose women's issues because women are all hysterical aren't they, and they just need a pat on the head to make them better.
 
Sly Saint said:
The IAPT Double Myth of Economic and Clinical Utility


http://www.cbtwatch.com/the-iapt-double-myth-of-economic-and-clinical-utility/
Click to expand...
In 2006 the Centre for Economic Performance stated that “the total loss of output due to depression and chronic anxiety is some £12 billion a year-1% of our total national income ”
Click to expand...
Looks like it's standard to inflate numbers wherever psychology creeps into medicine. Or I did the calculations wrong, but the ONS says the 2006 UK GDP was £1.8T, so £12B would be 0.6% of GDP. Of course no one uses "total national income" like this. GDP figures will be used. Sometimes GNP, but that doesn't make sense here.

Looking at the UK budget in 2006, it says total government revenues were £516B, so £12B would be 2.3%. I think they just rounded up from 0.6% here.

I don't know if it's worth looking, and I may have made a foggy mistake here, but this is in line with the tradition of inflating those costs, which makes this particular distortion especially suspect. Past behavior should always inform intent. Maybe worth looking if I didn't derp this, @dave30th?

Nevermind of course that "anxiety" and "depression" have no tests, are often determined, without validation, in as little as 12 seconds, and at best can be described as "may be associated with suspected-but-not-validated vague concepts that can be attributed to anxiety and/or depression", because it's all there is: association.

Especially in the context of IAPT, the idea that anxiety and depression "diagnoses", again without any validation, are supreme and can be costed while more extensive but nevertheless judgment-based diagnoses like ME cannot be considered valid is just absurdly dishonest.

Reminds me how in some countries they will always use the 10-year price tag for some government programs, while using annual figures for others. Manufacturing consent in full effect. Those figures are completely dishonest on purpose.
 
Sly Saint said:
this might have been posted elsewhere
from 2017 the partially costed proposal for adding Long term conditions to IAPT

(pdf)
Building the Business Case IAPT-LTC

https://www.healthylondon.org/wp-content/uploads/2017/11/IAPT-LTC-Building-the-Business-Case.pdf
Click to expand...

This seems shockingly poor in basic required quality. Reference 11 is the reference that apparently applies to their claim that IAPT reducing costs of sickness absence (I was looking it up because I wondered whether this study actually remembered that sickness absence gets logged in a different way if something becomes a disability-disability leave, or an appointment etc, so the 'official stamp' in itself could just be switching that to a different pile - along with of course the chance people actually get given adjustments 'whilst they are in treatment).

You go to reference 11 and it points you back to table 1 Annex. You then look through table 1 (with column 1 being the health condition) and it is full of references like 'A Dutch study found' then pointing back to xiii or another even tinier number to scroll back to the back of the doc to try and find.

Is that really OK? Talk about not giving two hoots about methodology, just the politics of saying 'evidence' and 'clearly'. Don't even put the reference in that anyone could look up and find without a shed-load of perserverance to get to the end of the goose chase.
 
Last edited:
MEMarge said:
Do you have time to flag it to the MS Society @Sly Saint
Click to expand...
would be better coming from someone more 'official'.
Also, I think the whole issue of MUS seems to be slightly morphing; eg this

Prevalence of Medically Unexplained Symptoms in Multiple Sclerosis and their Association with Psychological Factors.
  • June 2019
  • Conference: Annual Rehabilitation in Multiple Sclerosis (RIMS) Conference
  • At: Ljubljana
Abstract
Introduction: The estimation of the prevalence of functional or medically unexplained symptoms (MUS) in multiple sclerosis (MS) is essential because of the high level of distress and economic cost these symptoms cause in addition to the direct personal and financial burden associated with MS. MUS are found in 2/3 of neurological patients, but have not been systematically studied in conjunction with MS.
The present study aimed to determine the prevalence of MUS in a neurorehabilitation clinic.
Another objective of the research was to analyze the relationship between MUS and mental comorbidities, traumatic childhood experiences and negative life events.

Methods: The prevalence of MUS was assessed in 120 MS patients using a questionnaire where physicians and functional therapists rated the organicity of the symptoms on the 4-point Likert scale. MUS associated variables such as anxiety, depression, dissociation, traumatic childhood experiences and negative life events were collected using questionnaires.

Results: 52.5% of the examined MS patients show a fluctuating functional symptom enhancement in addition to organically caused symptoms; 7.5% of the patients have inconsistent findings that cannot be explained neurologically.
Furthermore, there is a consensus between physicians and functional therapists regarding organicity ratings. Moreover, symptoms of MS patients with clinically relevant psychopathological values are less organically explainable than in patients with values below the cut-off. Additionally, there are significant correlations between some of the psychopathology variables collected and the severity and number of symptoms reported by patients.

Discussion: These results show that MUS are found in a significant proportion of MS patients in addition to organically caused neurological symptoms. Psychopathological factors can be regarded as possible warning signs and risk factors that can produce or amplify functional symptomatology. The study results highlight the usefulness of the neurorehabilitative multidisciplinary approach in MS that considers both the psychological burden and the organically induced deficit.
Click to expand...
https://www.researchgate.net/public..._their_Association_with_Psychological_Factors

MUS seem to have become an entity of their own and are considered to be any symptoms that, in their opinion, cannot be directly attributable to the patients primary ailment.

between this and LTCs just about any patient with any illness is going to be referred to IAPT.
 
The UK’s IAPT Service Is an Abject Failure
By
Michael Scott

It is a longer article but ME/CFS and MUS in general are also mentioned:

IAPT appears not to so much follow the data, but to follow funding opportunities. It has branched out into territory were angels fear to tread: Medically Unexplained Symptoms (MUS). MUS is an umbrella term embracing conditions as diverse as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. IAPT’s contention is that exaggerated negative beliefs about symptoms, and maladaptive behaviours (e.g., avoidance), play a pivotal role in the maintenance of symptoms in these conditions. The therapeutic task, as they see it, is to then to modify these cognitions and behaviours.

What happens if a client protests that they have valid medical symptoms? Well, IAPT clinicians are taught not to openly disagree and not to say “it is all in your mind.” But to nevertheless continue to focus on the “exaggerations in beliefs and avoidance behaviours”—so much for honesty.

Along with Keith Geraghty from the University of Manchester, I have published a critique of this sojourn. We identified a series of seven core problems and failings of the IAPT, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment. We concluded that psychotherapy should not become the default option when patients have “medically unexplained symptoms.”

The term “medically unexplained symptoms” should be written in lowercase to avoid conveying the impression that a meaningful homogenous entity is being described. The term should not enter the taxonomy of disorders. Importantly, even the DSM-5 has shunned recourse to the term. But unfortunately, IAPT only pays lip service to the standard diagnostic criteria.​
 
Wyva said:
The UK’s IAPT Service Is an Abject Failure
By
Michael Scott


...The term “medically unexplained symptoms” should be written in lowercase to avoid conveying the impression that a meaningful homogenous entity is being described. The term should not enter the taxonomy of disorders. Importantly, even the DSM-5 has shunned recourse to the term. But unfortunately, IAPT only pays lip service to the standard diagnostic criteria.​
Click to expand...


In November 2019, IAPT leads submitted a request for addition of a new SNOMED CT Concept code for the term, "Somatic symptom disorder".

In 2021, IAPT successfully obtained addition of the term "Somatic symptom disorder" to SNOMED CT International Edition [1].

Rather than create a new Concept code, SNOMED International's terminology team approved the addition of "Somatic symptom disorder" under Synonyms to the existing SNOMED CT Concept code, 723916001 Bodily distress disorder. This decision was implemented for the International Edition's January 31, 2021 release.

The addition of this Synonyms term to the International Edition was absorbed by the UK Edition's May 12, 2021 release.

Concept code 723916001 Bodily distress disorder is mapped to F45.9 Somatoform disorder, unspecified in the SNOMED CT UK to ICD-10 Classification Map.

https://www.s4me.info/threads/updat...-terminology-systems.3912/page-24#post-352019

revised-iapt-3.4-presenting-complaints2.png



In the past, I have attempted to engage with Michael Scott in relation to the issue of incorporation of the term "Somatic symptom disorder" into the new IAPT Data Set, but he has not responded to my approaches nor published any of the comments I submitted to his blogs.


References:

1 IAPT request (submitted November 13, 2019) for addition of new Concept code for SNOMED CT UK Edition: https://isd.hscic.gov.uk/rsp-snomed/user/guest/request/view.jsf?request_id=29847

2 For the background to this request:
IAPT requests code for Somatic symptom disorder for SNOMED CT, Suzy Chapman, November 2020:
https://dxrevisionwatch.files.wordp...or-somatic-symptom-disorder-for-snomed-ct.pdf

3 Revised spreadsheet: IAPT v2.0 Terminology Mapping Guidance v3.4, 25 May 2021:
https://nhs-prod.global.ssl.fastly....apt_v2_terminology_mapping_guidance_v3.4.xlsx
 
Last edited:
Generally excellent - but what, on earth, does he mean by a "critique of this sojourn"?I have never heard of any usage of "sojourn" that would be appropriate, and it seems that neither have publishers of dictionaries
 
Last edited:
I do like this analogy....!
  1. 5ba31690496eb83930e7858478142cd2
    Gerard June 28, 2022 at 7:56
    It is also the abject failure of CBT. In his book “CBT: The Cognitive Behavioural Tsunami” Farhad Dalal sums up the simplistic thinking behind this approach as follows:

    “We observe a dog wagging its tail. We notice that only happy dogs wag their tails.

    We notice that unhappy dogs do not wag their tails.

    We deduce from this, that if unhappy dogs wagged their tails, they would become happy.

    We develop a treatment protocol which teaches unhappy dogs to learn to wag their tails.

    If they learn how to wag their tails, and then choose to wag their tails, then they will become happy.

    CBT techniques assume that it is possible to use this kind of reverse engineering to change feeling states.

    Happy dogs wag tails; therefore tail wagging should generate happiness.”
 
Last edited by a moderator:
Wyva said:
The UK’s IAPT Service Is an Abject Failure
By
Michael Scott

It is a longer article but ME/CFS and MUS in general are also mentioned:

IAPT appears not to so much follow the data, but to follow funding opportunities. It has branched out into territory were angels fear to tread: Medically Unexplained Symptoms (MUS). MUS is an umbrella term embracing conditions as diverse as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. IAPT’s contention is that exaggerated negative beliefs about symptoms, and maladaptive behaviours (e.g., avoidance), play a pivotal role in the maintenance of symptoms in these conditions. The therapeutic task, as they see it, is to then to modify these cognitions and behaviours.

What happens if a client protests that they have valid medical symptoms? Well, IAPT clinicians are taught not to openly disagree and not to say “it is all in your mind.” But to nevertheless continue to focus on the “exaggerations in beliefs and avoidance behaviours”—so much for honesty.

Along with Keith Geraghty from the University of Manchester, I have published a critique of this sojourn. We identified a series of seven core problems and failings of the IAPT, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment. We concluded that psychotherapy should not become the default option when patients have “medically unexplained symptoms.”

The term “medically unexplained symptoms” should be written in lowercase to avoid conveying the impression that a meaningful homogenous entity is being described. The term should not enter the taxonomy of disorders. Importantly, even the DSM-5 has shunned recourse to the term. But unfortunately, IAPT only pays lip service to the standard diagnostic criteria.​
Click to expand...


Good article. Very much needed to be said. My few thoughts:

- part of me wondered whether IAPT would 'eat itself' if going into more and more remote and scripted formats such as online with no person at all. Whereas the 'selling point' in CBT when debating it vs counselling was always that 'it could be measured', had a defined end point, and involved less talking and delving into the past just a focus on the future 'for those who don't like talking' just like with ATMs vs cashiers the personal touch can add and fill gaps when you get someone good who cares that might cover up failings in the actual defined treatment.

- however I can't help feeling like one issue with CBT is the context in which it tends to be doled out and seen. It reminds me of the concept education has of itself - cocreation ie someone doesn't 'buy education or a qualification' and certainly as you get higher up the qualification chain or mark scale the more independent work and thought would be expected. I wonder how much the courses themselves, but also the way in which they are sold and the contexts people are sent to these in emphasises this pressure. Particularly when used by workplaces for those who say their job is stressful.

Does a 'low mark' reflect on the individual rather than the treatment in this? And who can afford to give themselves a low mark. It's a course you've completed after all. And yes maybe a low mark sounds like it leads to more of the same but at a higher intensity. You can either try and explain why you'll say no to that or maybe tick enough boxes. It also sounds like you've finished the course so are you putting it into practice in which case you'll show it in your psychometric responses. Is that a test as much as anything else

In this context then that pressure might be more present when it is an online format. It becomes like failing an online course. Less implicit pressures from relationships with a person who has been friendly and put time in, but many weeks of yours - and probably 'you were supposed to do homework' etc.

- I don't think this is an issue with counselling where the relationship vs course is so straightforward that you either gel or don't, it helps or doesn't. It doesn't 'transform' you but takes a load off, talks things through etc.
 
Sly Saint said:
MUS seem to have become an entity of their own and are considered to be any symptoms that, in their opinion, cannot be directly attributable to the patients primary ailment.
Click to expand...

I agree with you. But it will be to everyone's disadvantage if this continues. Even doctors become ill sometimes. And I doubt that doctors are more honest than the rest of the population. So, lazy ones, doctors who dislike a patient, doctors who slept badly, doctors who just can't be bothered any more,... are all going to decide occasionally that they can't be bothered with the patient that just walked in the door, so if they think they can swing it they can tell the patient to get lost - or refer them to CBT.
 
Arnie Pye said:
I agree with you. But it will be to everyone's disadvantage if this continues. Even doctors become ill sometimes. And I doubt that doctors are more honest than the rest of the population. So, lazy ones, doctors who dislike a patient, doctors who slept badly, doctors who just can't be bothered any more,... are all going to decide occasionally that they can't be bothered with the patient that just walked in the door, so if they think they can swing it they can tell the patient to get lost - or refer them to CBT.
Click to expand...

Well that is what it is there for isn't it - change your attitude therapy to remove people out of GPs hair? I'm not sure it's the proportion you think. Once it's bought by the CCG (I know these have changed) and becomes a pathway and you've a job monitored to follow-the-required-action in a system set-up around costs and timeslots... it's more like dedicated and brave (and probably young as you see the ones who try and then the moment where the 'system' has given them the message and they've had to start toeing the line) not to.

After all the slides to sell it to the CCG literally say it 'saves them money at any price' specifically because this list of people they inaccurately state have been 'taking up 10% of the NHS's resources': https://www.virology.ws/2021/04/23/...rs-mis-citing-a-study-about-costs-to-the-nhs/ . And there are bums on seats to be achieved to make that saving - team effort required.

One could interpret it as marketing suggesting 'these are the people that are bleeding the NHS dry/you'll never get rid of/will stop you being able to help other patients'. If someone above you believes this sort of thing and puts processes in place.. that cost a fortune so they have to be used and then it will save them money, how hard is it for most to break that protocol?
 
You must log in or register to reply here.
Back
Top